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Septal flash is a prevalent and early dyssynchrony marker in transcatheter aortic valve replacement-induced left bundle branch block

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Abstract

New-onset left bundle branch block (LBBB) is a frequent complication after transcatheter aortic valve replacement (TAVR) and provides an opportunity to study dyssynchrony immediately following acute LBBB. This study aims to (1) assess echocardiographic dyssynchrony in acute TAVR-induced LBBB (TAVR-LBBB), and (2) compare dyssynchrony parameters among different patient groups with LBBB. The study enrolled all TAVR-LBBB patients at Ghent University Hospital between 2013 and 2019. First, acute TAVR-LBBB dyssynchrony was assessed by: (1) septal flash (SF); (2) interventricular mechanical delay (IVMD; cut-off ≥ 40 ms) and (3) presence of ‘classical dyssynchronous strain pattern’ assessed with speckle tracking. Secondly, acute TAVR-LBBB patients with SF (LBBBTAVR+SF) were compared to randomly selected LBBB-SF patients with preserved (LBBBSF+PEF) ànd reduced ejection fraction (LBBBSF+REF). In TAVR-LBBB patients (n = 25), SF was detected in 72% of patients, whereas only 5% of TAVR-LBBB patients showed a classical dyssynchronous strain pattern. IVMD in these TAVR-LBBB patients was 39 ms. In 90% of LBBBTAVR+SF patients, SF was observed within 24 h after LBBB onset. Among LBBB-SF patients, a classical strain pattern was more prevalent in LBBBSF+REF patients compared to LBBBTAVR+SF patients (80% vs. 7%; p < 0.001). IVMD was significantly longer in LBBBSF+PEF patients (52 ms; p = 0.002) and LBBBSF+REF patients (57 ms; p = 0.009) compared to LBBBTAVR+SF patients (37 ms). SF is an early and prevalent marker of LV dyssynchrony in acute TAVR-LBBB, whereas strain-based measures and IVMD do not appear to capture dyssynchrony at this early stage. Our findings from the comparative analysis generate the hypothesis that progressive LBBB-induced LV remodeling may be required for a ‘classical dyssynchrony strain pattern’ or significant IVMD to occur in TAVR-LBBB patients.

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References

  1. Calle S, Delens C, Kamoen V, De Pooter J, Timmermans F (2019) Septal flash: At the heart of cardiac dyssynchrony. Trends Cardiovasc Med. https://doi.org/10.1016/j.tcm.2019.03.008

    Article  PubMed  Google Scholar 

  2. Duchateau N, Sitges M, Doltra A, Fernandez-Armenta J, Solanes N, Rigol M et al (2014) Myocardial motion and deformation patterns in an experimental swine model of acute LBBB/CRT and chronic infarct. Int J Cardiovasc Imaging 30(5):875–887. https://doi.org/10.1007/s10554-014-0403-2

    Article  PubMed  Google Scholar 

  3. Aalen JM, Remme EW, Larsen CK, Andersen OS, Krogh M, Duchenne J et al (2019) Mechanism of abnormal septal motion in left bundle branch block: role of left ventricular wall interactions and myocardial scar. JACC Cardiovasc Imaging. https://doi.org/10.1016/j.jcmg.2018.11.030

    Article  PubMed  Google Scholar 

  4. Barake W, Witt CM, Vaidya VR, Cha YM (2019) Incidence and natural history of left bundle branch block induced cardiomyopathy. Circ Arrhythm Electrophysiol 12(9):e007393. https://doi.org/10.1161/CIRCEP.119.007393

    Article  PubMed  Google Scholar 

  5. Delgado V, Tops LF, Trines SA, Zeppenfeld K, Marsan NA, Bertini M et al (2009) Acute effects of right ventricular apical pacing on left ventricular synchrony and mechanics. Circ Arrhythm Electrophysiol 2(2):135–145. https://doi.org/10.1161/CIRCEP.108.814608

    Article  PubMed  Google Scholar 

  6. Tops LF, Schalij MJ, Bax JJ (2009) The effects of right ventricular apical pacing on ventricular function and dyssynchrony implications for therapy. J Am Coll Cardiol 54(9):764–776. https://doi.org/10.1016/j.jacc.2009.06.006

    Article  PubMed  Google Scholar 

  7. Houthuizen P, van der Boon RM, Urena M, Van Mieghem N, Brueren GB, Poels TT et al (2014) Occurrence, fate and consequences of ventricular conduction abnormalities after transcatheter aortic valve implantation. EuroIntervention 9(10):1142–1150. https://doi.org/10.4244/EIJV9I10A194

    Article  PubMed  Google Scholar 

  8. Dobson LE, Musa TA, Uddin A, Fairbairn TA, Bebb OJ, Swoboda PP et al (2017) The impact of trans-catheter aortic valve replacement induced left-bundle branch block on cardiac reverse remodeling. J Cardiovasc Magn Reson 19(1):22. https://doi.org/10.1186/s12968-017-0335-9

    Article  PubMed  PubMed Central  Google Scholar 

  9. Klein MR, Sundh F, Simlund J, Harrison JK, Jackson KP, Hughes GC et al (2015) Immediate mechanical effects of acute left bundle branch block by speckle tracked strain. J Electrocardiol 48(4):643–651. https://doi.org/10.1016/j.jelectrocard.2015.05.005

    Article  PubMed  Google Scholar 

  10. Klaeboe LG, Brekke PH, Lie OH, Aaberge L, Haugaa KH, Edvardsen T (2019) Classical mechanical dyssynchrony is rare in transcatheter aortic valve implantation-induced left bundle branch block. Eur Heart J Cardiovasc Imaging 20(3):271–278. https://doi.org/10.1093/ehjci/jey127

    Article  PubMed  Google Scholar 

  11. Surkova E, Badano LP, Bellu R, Aruta P, Sambugaro F, Romeo G et al (2017) Left bundle branch block: from cardiac mechanics to clinical and diagnostic challenges. Europace 19(8):1251–1271. https://doi.org/10.1093/europace/eux061

    Article  PubMed  Google Scholar 

  12. Brignole M, Auricchio A, Baron-Esquivias G, Bordachar P, Boriani G, Breithardt OA et al (2013) 2013 ESC guidelines on cardiac pacing and cardiac resynchronization therapy: the task force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC) Developed in collaboration with the European Heart Rhythm Association (EHRA). Europace 15(8):1070–1118. https://doi.org/10.1093/europace/eut206

    Article  PubMed  Google Scholar 

  13. Surawicz B, Childers R, Deal BJ, Gettes LS, Bailey JJ, Gorgels A et al (2009) AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part III: intraventricular conduction disturbances: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology. Circulation 119(10):e235–e240. https://doi.org/10.1161/CIRCULATIONAHA.108.191095

    Article  PubMed  Google Scholar 

  14. Strauss DG, Selvester RH, Wagner GS (2011) Defining left bundle branch block in the era of cardiac resynchronization therapy. Am J Cardiol 107(6):927–934. https://doi.org/10.1016/j.amjcard.2010.11.010

    Article  PubMed  Google Scholar 

  15. De Boeck BW, Teske AJ, Meine M, Leenders GE, Cramer MJ, Prinzen FW et al (2009) Septal rebound stretch reflects the functional substrate to cardiac resynchronization therapy and predicts volumetric and neurohormonal response. Eur J Heart Fail 11(9):863–871. https://doi.org/10.1093/eurjhf/hfp107

    Article  CAS  PubMed  Google Scholar 

  16. Cazeau S, Bordachar P, Jauvert G, Lazarus A, Alonso C, Vandrell MC et al (2003) Echocardiographic modeling of cardiac dyssynchrony before and during multisite stimulation: a prospective study. Pacing Clin Electrophysiol 26(2):137–143. https://doi.org/10.1046/j.1460-9592.2003.00003.x

    Article  CAS  PubMed  Google Scholar 

  17. Risum N, Strauss D, Sogaard P, Loring Z, Hansen TF, Bruun NE et al (2013) Left bundle-branch block: the relationship between electrocardiogram electrical activation and echocardiography mechanical contraction. Am Heart J 166(2):340–348. https://doi.org/10.1016/j.ahj.2013.04.005

    Article  PubMed  Google Scholar 

  18. Suffoletto MS, Dohi K, Cannesson M, Saba S, Gorcsan J 3rd (2006) Novel speckle-tracking radial strain from routine black-and-white echocardiographic images to quantify dyssynchrony and predict response to cardiac resynchronization therapy. Circulation 113(7):960–968. https://doi.org/10.1161/CIRCULATIONAHA.105.571455

    Article  PubMed  Google Scholar 

  19. Doltra A, Bijnens B, Tolosana JM, Borras R, Khatib M, Penela D et al (2014) Mechanical abnormalities detected with conventional echocardiography are associated with response and midterm survival in CRT. JACC Cardiovasc Imaging 7(10):969–979. https://doi.org/10.1016/j.jcmg.2014.03.022

    Article  PubMed  Google Scholar 

  20. Vaillant C, Martins RP, Donal E, Leclercq C, Thebault C, Behar N et al (2013) Resolution of left bundle branch block-induced cardiomyopathy by cardiac resynchronization therapy. J Am Coll Cardiol 61(10):1089–1095. https://doi.org/10.1016/j.jacc.2012.10.053

    Article  PubMed  Google Scholar 

  21. Jorgensen TH, De Backer O, Gerds TA, Bieliauskas G, Svendsen JH, Sondergaard L (2019) Mortality and heart failure hospitalization in patients with conduction abnormalities after transcatheter aortic valve replacement. JACC Cardiovasc Interv 12(1):52–61. https://doi.org/10.1016/j.jcin.2018.10.053

    Article  PubMed  Google Scholar 

  22. Chamandi C, Barbanti M, Munoz-Garcia A, Latib A, Nombela-Franco L, Gutierrez-Ibanez E et al (2019) Long-term outcomes in patients with new-onset persistent left bundle branch block following TAVR. JACC Cardiovasc Interv 12(12):1175–1184. https://doi.org/10.1016/j.jcin.2019.03.025

    Article  PubMed  Google Scholar 

  23. Donal E, Galli E, Cosyns B (2019) Twenty years after starting cardiac resynchronization therapy, do we understand the electromechanical coupling? Eur Heart J Cardiovasc Imaging 20(3):257–259. https://doi.org/10.1093/ehjci/jey152

    Article  PubMed  Google Scholar 

  24. Corteville B, De Pooter J, De Backer T, El Haddad M, Stroobandt R, Timmermans F (2017) The electrocardiographic characteristics of septal flash in patients with left bundle branch block. Europace 19(1):103–109. https://doi.org/10.1093/europace/euv461

    Article  PubMed  Google Scholar 

  25. Vernooy K, Verbeek XA, Peschar M, Crijns HJ, Arts T, Cornelussen RN et al (2005) Left bundle branch block induces ventricular remodelling and functional septal hypoperfusion. Eur Heart J 26(1):91–98. https://doi.org/10.1093/eurheartj/ehi008

    Article  PubMed  Google Scholar 

  26. Sarvari SI, Sitges M, Sanz M, Tolosana Viu JM, Edvardsen T, Stokke TM et al (2017) Left ventricular dysfunction is related to the presence and extent of a septal flash in patients with right ventricular pacing. Europace 19(2):289–296. https://doi.org/10.1093/europace/euw020

    Article  PubMed  Google Scholar 

  27. Nazif TMCS, George I, Dizon JM, Hahn RT, Crowley A, Alu MC et al (2019) New-onset left bundle branch block after transcatheter aortic valve replacement is associated with adverse long-term clinical outcomes in intermediate-risk patients: an analysis from the PARTNER II trial. Eur Heart J 40:2218–2227. https://doi.org/10.1093/eurheartj/ehz227

    Article  PubMed  Google Scholar 

  28. Stankovic I, Prinz C, Ciarka A, Daraban AM, Kotrc M, Aarones M et al (2016) Relationship of visually assessed apical rocking and septal flash to response and long-term survival following cardiac resynchronization therapy (PREDICT-CRT). Eur Heart J Cardiovasc Imaging 17(3):262–269. https://doi.org/10.1093/ehjci/jev288

    Article  PubMed  Google Scholar 

  29. Carrabba N, Valenti R, Migliorini A, Marrani M, Cantini G, Parodi G et al (2015) Impact on left ventricular function and remodeling and on 1-year outcome in patients with left bundle branch block after transcatheter aortic valve implantation. Am J Cardiol 116(1):125–131. https://doi.org/10.1016/j.amjcard.2015.03.054

    Article  PubMed  Google Scholar 

  30. Mack MJ, Leon MB, Thourani VH, Makkar R, Kodali SK, Russo M et al (2019) Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. N Engl J Med 380(18):1695–1705. https://doi.org/10.1056/NEJMoa1814052

    Article  PubMed  Google Scholar 

  31. Popma JJ, Deeb GM, Yakubov SJ, Mumtaz M, Gada H, O'Hair D et al (2019) Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients. N Engl J Med 380(18):1706–1715. https://doi.org/10.1056/NEJMoa1816885

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Cardiology, University Hospital Ghent, Corneel Heymanslaan 10, 9000, Ghent, Belgium

    Simon Calle, Mathieu Coeman, Karen Desmet, Tine De Backer, Marc De Buyzere, Jan De Pooter & Frank Timmermans

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  1. Simon Calle
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  2. Mathieu Coeman
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Correspondence to Simon Calle.

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Supplementary file1 (DOCX 38 kb)

10554_2020_1791_MOESM2_ESM.avi

Supplementary file2 (AVI 37893 kb). Video 1 Transthoracic echocardiogram of a 72-years-old male patient with new onset TAVR-induced LBBB, showing mild septal flash by visual assessment

10554_2020_1791_MOESM3_ESM.avi

Supplementary file3 (AVI 45208 kb). Video 2 Transthoracic echocardiogram of a 76-years-old male patient with non-procedural-induced LBBB and preserved left ventricular ejection fraction, showing moderate septal flash by visual assessment

10554_2020_1791_MOESM4_ESM.avi

Supplementary file4 (AVI 36754 kb). Video 3 Transthoracic echocardiogram of a 63-years-old female patient with non-procedural-induced LBBB and reduced left ventricular ejection fraction, showing prominent septal flash by visual assessment

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Calle, S., Coeman, M., Desmet, K. et al. Septal flash is a prevalent and early dyssynchrony marker in transcatheter aortic valve replacement-induced left bundle branch block. Int J Cardiovasc Imaging 36, 1041–1050 (2020). https://doi.org/10.1007/s10554-020-01791-y

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